wound care

Traumatic Traumatic Injuries of the Injuries of the

CNSCNS

VOCN42BVOCN42B

Mar, 2012Mar, 2012

During recovery from a cerebrovascular During recovery from a cerebrovascular accident (CVA), a female client is given nothing accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To by mouth, to help prevent aspiration. To determine when the client is ready for a liquid determine when the client is ready for a liquid diet, the nurse assesses the client’s swallowing diet, the nurse assesses the client’s swallowing ability once each shift. This assessment ability once each shift. This assessment evaluates:evaluates:

a. cranial nerves I and II.a. cranial nerves I and II. b. cranial nerves III and V.b. cranial nerves III and V. c. cranial nerves VI and VIII.c. cranial nerves VI and VIII. d. cranial nerves IX and X.d. cranial nerves IX and X.

Learning ObjectivesLearning Objectives

Differences b/t concussion & contusionDifferences b/t concussion & contusion Differences b/t epidural, subdural, & Differences b/t epidural, subdural, &

intercerebral heamatomasintercerebral heamatomas Nursing management for head injuryNursing management for head injury Explain spinal shock, listings four sxsExplain spinal shock, listings four sxs Autonomic dysreflexiaAutonomic dysreflexia Long-term complications of spinal cord injuryLong-term complications of spinal cord injury Difference b/t intramedullary and Difference b/t intramedullary and

extramedullary spinal nerve root extramedullary spinal nerve root compressioncompression

Head injuriesHead injuries

ConcussionConcussion ContusionContusion Cerebral HematomasCerebral Hematomas Skull FracturesSkull Fractures Spinal cord injuriesSpinal cord injuries Spinal nerve root compressionSpinal nerve root compression

Traumatic brain injury Traumatic brain injury (TBI)(TBI)

TBI is a contributing factor to a third TBI is a contributing factor to a third (30.5%) of all injury-related deaths in the (30.5%) of all injury-related deaths in the United States United States

Each year, an estimated 1.7 million people Each year, an estimated 1.7 million people sustain a TBI annually.1 Of them: sustain a TBI annually.1 Of them: 52,000 die, 52,000 die, 275,000 are hospitalized, and 275,000 are hospitalized, and 1.365 million, nearly 80%, are treated and 1.365 million, nearly 80%, are treated and

released from an emergency department.released from an emergency department.

Severe TBI - Severe TBI - DemographicsDemographics

1.5 million cases per year in U1.5 million cases per year in U

Causes: Causes: Motor vehicle Motor vehicle accidentaccident (~45%), falls (~45%), falls (~30%), occupational (~30%), occupational accidents (~10%), accidents (~10%), recreational accidents recreational accidents (~10%), assaults (~5%)(~10%), assaults (~5%)

Highest risk: children, Highest risk: children, adolescent/young adult menadolescent/young adult men, , elderlyelderly

(Population (Population 300millions)300millions)

Traumatic brain injury Traumatic brain injury (TBI)(TBI)

Traumatic brain injury (TBI), a form Traumatic brain injury (TBI), a form ofof acquired brain injury, occurs when acquired brain injury, occurs when a sudden trauma causes damage to a sudden trauma causes damage to the brain the brain

Result when the head suddenly and Result when the head suddenly and violently hits an object, or when an violently hits an object, or when an object pierces the skull and enters object pierces the skull and enters brain tissuebrain tissue

TBITBI Symptoms of a TBI can be mild, moderate, Symptoms of a TBI can be mild, moderate,

or severe, depending on the extent of the or severe, depending on the extent of the damage to the braindamage to the brain

With a mild TBI may remain conscious or With a mild TBI may remain conscious or may experience a loss of consciousness may experience a loss of consciousness for a few seconds or minutesfor a few seconds or minutes

Other symptoms of mild TBI include Other symptoms of mild TBI include headache, confusion, lightheadedness, headache, confusion, lightheadedness,

dizziness, blurred vision or tired eyes, ringing dizziness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or in the ears, bad taste in the mouth, fatigue or lethargy, a change in sleep patterns, lethargy, a change in sleep patterns, behavioral or mood changes, and trouble with behavioral or mood changes, and trouble with memory, concentration, attention, or thinking memory, concentration, attention, or thinking

TBITBI

With a moderate or severe TBI With a moderate or severe TBI May also have a headache that gets May also have a headache that gets

worse or does not go away, repeated worse or does not go away, repeated vomiting or nausea, convulsions or vomiting or nausea, convulsions or seizures, an inability to awaken from seizures, an inability to awaken from sleep, dilation of one or both pupils of sleep, dilation of one or both pupils of the eyes, slurred speech, weakness or the eyes, slurred speech, weakness or numbness in the extremities, loss of numbness in the extremities, loss of coordination, and increased confusion, coordination, and increased confusion, restlessness, or agitation. restlessness, or agitation.

A female client who was trapped inside a car A female client who was trapped inside a car for hours after a head-on collision is rushed for hours after a head-on collision is rushed

to the emergency department with multiple to the emergency department with multiple

injuries. During the neurologic examination, injuries. During the neurologic examination,

the client responds to painful stimuli with the client responds to painful stimuli with

decerebrate posturing. This finding indicates decerebrate posturing. This finding indicates

damage to which part of the brain?damage to which part of the brain? a. Diencephalona. Diencephalon b. Medullab. Medulla c. Midbrainc. Midbrain d. Cortexd. Cortex

ConcussionConcussion Result from a blow to Result from a blow to

the head that jars the the head that jars the brainbrain

Consequence of Consequence of falling, striking the falling, striking the head against a hard head against a hard surface, battering surface, battering during boxing, or during boxing, or being a victim of being a victim of violenceviolence

Result in diffuse and Result in diffuse and microscopic injury to microscopic injury to the brainthe brain

ConcussionConcussion

Sign and symptomsSign and symptoms Brief lapse of consciousness, Brief lapse of consciousness, temporarytemporary

disorientation, headache, double or disorientation, headache, double or blurred visionblurred vision

Emotional irritationEmotional irritation Diagnostic testsDiagnostic tests

CT, MRICT, MRI

ConcussionConcussion

TreatmentTreatment Stop activities temporaryStop activities temporary Mild analgesics (Acetaminophen)Mild analgesics (Acetaminophen)

Nursing ManagementNursing Management Neurologic assessmentNeurologic assessment Watch pt closely for ICP, Watch pt closely for ICP,

Behavioral alterations, sleepiness, Behavioral alterations, sleepiness, personality changes, vomiting, speech or personality changes, vomiting, speech or gait disturbancesgait disturbances

ContusionContusion

ContusionContusion

A contusion is more serious than a A contusion is more serious than a concussionconcussion

Result in bruising, hemorrage of Result in bruising, hemorrage of superficial cerebral tissuesuperficial cerebral tissue

Coup injuryCoup injury Contrecoup injuryContrecoup injury

ContusionContusion

Signs and symptomsSigns and symptoms Depends on the severity of the blowDepends on the severity of the blow Hypotension, rapid and weak pulse, Hypotension, rapid and weak pulse,

shallow respirations, loss of shallow respirations, loss of consciousness, pale, clammy skinconsciousness, pale, clammy skin

Temporary amnesiaTemporary amnesia Permanent brain damagePermanent brain damage

ContusionContusion

Diagnostic testsDiagnostic tests Skull x-raySkull x-ray CTCT MRIMRI

Medical treatmentMedical treatment Drug therapyDrug therapy Mechanical ventilationMechanical ventilation

ContusionContusion

Nursing managementNursing management Observe of changes of LOCObserve of changes of LOC Signs of ICP Signs of ICP Nerologic changesNerologic changes Respiratory distressRespiratory distress Changes in VS q1-2 hrsChanges in VS q1-2 hrs

Cerebral HematomasCerebral Hematomas Bleeding within the Bleeding within the

skullskull High risk for High risk for

receiving receiving anticolagulant anticolagulant therapy, underlying therapy, underlying bleeding disorder bleeding disorder such as hemophilia, such as hemophilia, thrombocytopenia, thrombocytopenia, leukemia, aplastic leukemia, aplastic anemiaanemia

Types of HematomaTypes of Hematoma

Epidural hematomaEpidural hematoma From middle From middle

meningeal artery meningeal artery bleedingbleeding

Blood in above the Blood in above the duradura

Charaterized by Charaterized by rapidly progressive rapidly progressive neurologic neurologic deteriorationdeterioration


Subdural Subdural hematomahematoma Result from venous Result from venous

bleedingbleeding Gradually Gradually

accumulating in the accumulating in the space below the space below the duradura


Intracerebral Intracerebral hematomahematoma Bleeing within the Bleeing within the

brain d/t open or brain d/t open or closed head injury, closed head injury, ruptured cerebral ruptured cerebral aneurysmaneurysm

Cerebral HematomasCerebral Hematomas

Signs and symptomsSigns and symptoms volume of brain contents and ICPvolume of brain contents and ICP

Disrupts blood flow and cause the brain Disrupts blood flow and cause the brain become ischemic and hypoxicbecome ischemic and hypoxic

Uncal herniation: affect the vital centers for Uncal herniation: affect the vital centers for respiration, heart rate, and blood pressure, respiration, heart rate, and blood pressure, cranial nerve functionscranial nerve functions


Diagnostic testsDiagnostic tests Rapidly and severity of neurologic Rapidly and severity of neurologic

changeschanges Effects on autoregulationEffects on autoregulation

BrainBrain’’s ability to provide sufficient arterial s ability to provide sufficient arterial blood flow despite ICPblood flow despite ICP

MRI, CT: show densities MRI, CT: show densities

Medical interventionMedical intervention Surgical emergencySurgical emergency

magnetic resonance magnetic resonance angiogram (MRA)angiogram (MRA)

Is a type of Is a type of magnetic resonance imaging (MRI) scan that uses a magnetic field and scan that uses a magnetic field and pulses of radio wave energy to pulses of radio wave energy to provide pictures of provide pictures of blood vessels vessels inside the body. inside the body.

In many cases MRA can provide In many cases MRA can provide information that cannot be obtained information that cannot be obtained from an from an X-ray, , ultrasound, or , or computed tomography (CT) scan..


Surgical managementSurgical management Drilling holes (Burr holes): relieve Drilling holes (Burr holes): relieve

pressure, remove the clot, stopping the pressure, remove the clot, stopping the bleedingbleeding

Epidural hematomas require more Epidural hematomas require more prompt interventionprompt intervention

CraniotomyCraniotomy CraniectomyCraniectomy CranioplastyCranioplasty

CraniotomyCraniotomy

CraniectomyCraniectomy

Removal of a Removal of a portion of a cranial portion of a cranial bonebone

CranioplastyCranioplasty

The repair of a defect in a cranial boneThe repair of a defect in a cranial bone

Complications: cerebral edema, Complications: cerebral edema, infection, neurogenic shock, increased infection, neurogenic shock, increased ICP, seizures, leak of CSFICP, seizures, leak of CSF


Nursing ManagementNursing Management Obtain a history of the injury, exam Obtain a history of the injury, exam

neurologicneurologic VS, LOC, Pupil, motor, sensoryVS, LOC, Pupil, motor, sensory

Pre-op nursing carePre-op nursing care Post-op nursing carePost-op nursing care

VS (hyperthermia), neuro examVS (hyperthermia), neuro exam Osmotic diuretics, anticonvulsants, Osmotic diuretics, anticonvulsants,

corticosteroidcorticosteroid

The nurse is performing a mental status The nurse is performing a mental status examination on a male client diagnosed examination on a male client diagnosed with subdural hematoma. This test with subdural hematoma. This test assesses which of the following?assesses which of the following?

a. Cerebellar functiona. Cerebellar function b. Intellectual functionb. Intellectual function c. Cerebral functionc. Cerebral function d. Sensory functiond. Sensory function

The nurse is caring for a male client The nurse is caring for a male client diagnosed with a cerebral aneurysm diagnosed with a cerebral aneurysm who reports a severe headache. Which who reports a severe headache. Which action should the nurse perform?action should the nurse perform?

a. Sit with the client for a few a. Sit with the client for a few minutes.minutes.

b. Administer an analgesic.b. Administer an analgesic. c. Inform the nurse manager.c. Inform the nurse manager. d. Call the physician immediately.d. Call the physician immediately.

Skull FracturesSkull Fractures

A break in the craniumA break in the cranium TypesTypes

Simple: linear crack Simple: linear crack Depressed: broken Depressed: broken

bone pushed towardbone pushed toward

the brainthe brain Comminuted: bone Comminuted: bone

splintered into fragmentssplintered into fragments


Result from a blow to the headResult from a blow to the head Open head injury/closed head injuryOpen head injury/closed head injury Basilar skull fractures (i.e. base of Basilar skull fractures (i.e. base of

skull fracturesskull fractures)) A high incidence of dural tears and thus A high incidence of dural tears and thus

a higher than average risk of meningitisa higher than average risk of meningitis Cause edema on the origin of spinal cord Cause edema on the origin of spinal cord

, interfere with circulation of CSF, interfere with circulation of CSF Allow CSF to leak from the nose and earsAllow CSF to leak from the nose and ears

Basilar skull fracturesBasilar skull fractures Rhinorrhea, Rhinorrhea,

Otorrhea, Otorrhea,

BattleBattle’’s sign,s sign,

Orbital ecchymosis Orbital ecchymosis

(Raccoon eyes)(Raccoon eyes)


Signs and symptomsSigns and symptoms Localized HA, bruise, bump, lacerationLocalized HA, bruise, bump, laceration Depends on areaDepends on area


Dx testsDx tests Skull x-ray, CT, MRISkull x-ray, CT, MRI

Medical/surgical managementMedical/surgical management Simple Fx: BR, close observationSimple Fx: BR, close observation Depressed FX: craniotomyDepressed FX: craniotomy Osmotic diuretics, anticonvulsants, Osmotic diuretics, anticonvulsants, corticosteroid???corticosteroid???


Nursing ManagementNursing Management VS, Neuro exam q 1hrVS, Neuro exam q 1hr To detect CSF drainage: halo signTo detect CSF drainage: halo sign

Spinal Cord InjurySpinal Cord Injury

Serious and fatalSerious and fatal Cervical and lumbar vertebrae are Cervical and lumbar vertebrae are

the most commonthe most common EtiologyEtiology

Accidents & violenceAccidents & violence


Signs and Signs and symptomssymptoms Bleeding, nerve Bleeding, nerve

compression, compression, sensory & mortor sensory & mortor dysfunctiondysfunction

Tetraplegia=quadriTetraplegia=quadriplegiaplegia

ParaplegiaParaplegia

22. A male client is admitted with a 22. A male client is admitted with a cervical spine injury sustained during a cervical spine injury sustained during a diving accident. When planning this client’s diving accident. When planning this client’s care, the nurse should assign highest care, the nurse should assign highest priority to which nursing diagnosis?priority to which nursing diagnosis?

a. Impaired physical mobilitya. Impaired physical mobility b. Ineffective breathing patternb. Ineffective breathing pattern c. Disturbed sensory perception (tactile)c. Disturbed sensory perception (tactile) d. Self-care deficient: Dressing/groomingd. Self-care deficient: Dressing/grooming


ComplicationsComplications Spinal shock: loss of sympathetic reflex Spinal shock: loss of sympathetic reflex

activityactivity Immediate loss of all cord functionsImmediate loss of all cord functions Hypotension, bradycardia, warm, dry skin, Hypotension, bradycardia, warm, dry skin,

resp failure, bowel & bladder distention, resp failure, bowel & bladder distention, poiklothermia (no perspire)poiklothermia (no perspire)

Autonomic dysreflexiaAutonomic dysreflexia SCI at level T6 or higherSCI at level T6 or higher An exaggerated sympathetic nervous systemAn exaggerated sympathetic nervous system

Autonomic DysreflexiaAutonomic Dysreflexia

AD occurs in episodesAD occurs in episodes The first one typically happens about The first one typically happens about

4 to 6 months after the SCI occurred4 to 6 months after the SCI occurred Episodes are usually triggered by Episodes are usually triggered by

irritation irritation The irritation, often as minor as a full The irritation, often as minor as a full

bladder, causes an abnormal response bladder, causes an abnormal response in the nervous system in the nervous system

Autonomic Autonomic dysreflexiadysreflexia Severe headacheSevere headache Changes in heart rateChanges in heart rate Sweating and Sweating and

blotchiness of the skin blotchiness of the skin above the SCI, and above the SCI, and pale, cold skin below itpale, cold skin below it

Blurred visionBlurred vision Nasal congestionNasal congestion AnxietyAnxiety NauseaNausea Goose bumpsGoose bumps

Autonomic DysreflexiaAutonomic Dysreflexia

Management Management Administer antihypertensivesAdminister antihypertensives Raising headRaising head Relieve causeRelieve cause Prevention is the best treatmentPrevention is the best treatment

SCI ComplicationsSCI Complications Pressure ulcersPressure ulcers Respiratory infectionsRespiratory infections Urinary and fecal impairmentUrinary and fecal impairment Spasticity and contracturesSpasticity and contractures Weight changeWeight change Calcium depletionCalcium depletion Urinary calculiUrinary calculi Sexual dysfunctionSexual dysfunction PainPain

A male client has a history of painful, continuous A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg P.O. twice daily. prescribes diazepam (Valium), 2 mg P.O. twice daily. In addition to being used to relieve painful muscle In addition to being used to relieve painful muscle spasms, diazepam also is recommended for:spasms, diazepam also is recommended for:

a. long-term treatment of epilepsy.a. long-term treatment of epilepsy. b. postoperative pain management of laminectomy b. postoperative pain management of laminectomy

clients.clients. c. postoperative pain management of diskectomy c. postoperative pain management of diskectomy

clientsclients d. treatment of spasticity associated with spinal cord d. treatment of spasticity associated with spinal cord

lesions.lesions.

Spinal Nerve Root Spinal Nerve Root CompressionCompression


Intramedullary, extramedullaryIntramedullary, extramedullary Etiology: trauma, herniated disks, Etiology: trauma, herniated disks,

tumors, age, tumors, age, The level of the three lower lumbar The level of the three lower lumbar

disksdisks


Signs and symptomsSigns and symptoms Weakness, paralysis, pain, and Weakness, paralysis, pain, and

paresthesia (numbness, tingling)paresthesia (numbness, tingling) Diagnostic testsDiagnostic tests

Spinal x-raySpinal x-ray CTCT MRIMRI MyelographyMyelography EMGEMG


Medical managementMedical management Immobilization the spine with a collar or Immobilization the spine with a collar or

bracebrace Br with a firm mattressBr with a firm mattress Skin tractionSkin traction Hot moist packsHot moist packs Muscle relaxantsMuscle relaxants


Surgical ManagementSurgical Management Diskectomy: removal of the ruptured Diskectomy: removal of the ruptured

diskdisk Laminectomy: removal of the posterior Laminectomy: removal of the posterior

arch of a vertebra (herniated disk, arch of a vertebra (herniated disk, tumor, blood clot, bone spur..)tumor, blood clot, bone spur..)

Diskectomy with spinal fusionDiskectomy with spinal fusion


Medical managementMedical management Immobilization the spine with a collar or Immobilization the spine with a collar or

bracebrace Br with a firm mattressBr with a firm mattress Skin tractionSkin traction Hot moist packsHot moist packs Muscle relaxantsMuscle relaxants


Surgical ManagementSurgical Management Diskectomy: removal of the ruptured Diskectomy: removal of the ruptured

diskdisk Laminectomy: removal of the posterior Laminectomy: removal of the posterior

arch of a vertebra (herniated disk, arch of a vertebra (herniated disk, tumor, blood clot, bone spur..)tumor, blood clot, bone spur..)

Diskectomy with spinal fusionDiskectomy with spinal fusion

Symptoms of basilar skull fractures?Symptoms of basilar skull fractures? WhatWhat’’s the purpose of anticonvulsant s the purpose of anticonvulsant

phenytoin to the pt?phenytoin to the pt? What are common sites and causes What are common sites and causes

of spinal cord injuries?of spinal cord injuries? What is the purpose of Burr holes?What is the purpose of Burr holes? Describe the usual symptoms of Describe the usual symptoms of

spinal nerve root compression?spinal nerve root compression?

1. If a male client experienced a 1. If a male client experienced a cerebrovascular accident (CVA) that cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse damaged the hypothalamus, the nurse would anticipate that the client has would anticipate that the client has problems with:problems with:

a. body temperature control.a. body temperature control. b. balance and equilibrium.b. balance and equilibrium. c. visual acuity.c. visual acuity. d. thinking and reasoning.d. thinking and reasoning.


Nursing ManagementNursing Management Firm mattress or bedboard: support Firm mattress or bedboard: support

spine and promote alignmentspine and promote alignment Bedrest, semifowlerBedrest, semifowler’’ss Vest tractionVest traction Log-rollingLog-rolling Moist heat, muscle relaxant, pain Moist heat, muscle relaxant, pain

managementmanagement

A contusion caused when the head if A contusion caused when the head if struck directly?struck directly?

T or F? A contusion results in diffuse and T or F? A contusion results in diffuse and microscopic injury to the brainmicroscopic injury to the brain

A is a surgical opening in the skullA is a surgical opening in the skull To detect any CSF drainage the nurse To detect any CSF drainage the nurse

looks for a , which is a blood stain looks for a , which is a blood stain surrounded by a clear or yellowish stainsurrounded by a clear or yellowish stain

An lesion is a type of spinal nerve An lesion is a type of spinal nerve root compression that involves the spinal root compression that involves the spinal cordcord

Symptoms of basilar skull fractures?Symptoms of basilar skull fractures? WhatWhat’’s the purpose of anticonvulsant s the purpose of anticonvulsant

phenytoin to the pt?phenytoin to the pt? What are common sites and causes What are common sites and causes

of spinal cord injuries?of spinal cord injuries? What is the purpose of Burr holes?What is the purpose of Burr holes? Describe the usual symptoms of Describe the usual symptoms of

spinal nerve root compression?spinal nerve root compression?

1. If a male client experienced a 1. If a male client experienced a cerebrovascular accident (CVA) that cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse damaged the hypothalamus, the nurse would anticipate that the client has would anticipate that the client has problems with:problems with:

a. body temperature control.a. body temperature control. b. balance and equilibrium.b. balance and equilibrium. c. visual acuity.c. visual acuity. d. thinking and reasoning.d. thinking and reasoning.

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Documents

formtraumatic brain

cranial nerves

formofofacquired brain

aacquired brain injury

brain tissuepierces

ofall injuryrelated

sxsexplain spinal shock

tired eyes